You are welcome to use the following online forms to refer a patient to one of our facilities. I am a healthcare professional referring a patient for…

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Healthcare professionals wishing to refer a patient for imaging may complete the download or online referral form below. This form will be submitted to our appointments coordinators who will then contact the patient directly to arrange an appointment.

Patients may arrange an appointment by telephone or email, although a referral will always be required to confirm a booking.

PDF VERSION

For assistance, please call the Queen Square Imaging Centre on tel: 020 7833 2513 or email imaging@qsprivatehealthcare.com
Please complete the form below to refer a patient for an MRI scan
  • Patient details
  • Date Format: MM slash DD slash YYYY
  • Insurer details (if applicable)
  • Examination / Procedure
  • Safety check
  • Please contact the Imaging Centre if there are any concerns over a contra-indication to MRI
  • Referral details
  • Date Format: MM slash DD slash YYYY

Referrals made be made directly to any one of our consultants using the contact details provided for each specialist in the Our Experts section of this website.

Should you require assistance in identifying an appropriate specialist, please download or complete online, and submit the following form and one of our referral coordinators will be happy to assist.

PDF VERSION

For further assistance, please call tel: 020 3448 8948 or email referrals@qsprivatehealthcare.com

Please complete the form below to arrange a consultation appointment
  • Patient Details
  • Date Format: DD slash MM slash YYYY
  • Insurance details (if applicable)
  • Referrer's Details
  • Referral Details
  • Date Format: DD slash MM slash YYYY
  • (Please include supporting documents as necessary)
  • Referring Clinician:
  • Please attach any files below
  • Date Format: DD slash MM slash YYYY